Nursing Outlook Lead Article-Competency Definitions and KSA's

http://www.nursingoutlook.org

Quality and Safety Education for Nurses

 Nursing Outlook

Linda Cronenwett, PhD, RN, FAAN, Professor and Dean, School of Nursing, University of North Carolina at Chapel Hill

Gwen Sherwood, PhD, RN, FAAN, Professor and Associate Dean for Academic Affairs, School of Nursing, University of North Carolina at Chapel Hill

Jane Barnsteiner, PhD, RN, FAAN, Professor and Director of Translational Research, School of Nursing and Hospital of the University of Pennysylvania

Joanne Disch, PhD, RN, FAAN, Kathyrn R. and C. Walton Lillehei Professor and Director of the Densford International Center for Nursing Leadership, School of Nursing, University of Minnesota

Jean Johnson, PhD, RN-C, FAAN, Senior Associate Dean for Health Sciences, The George Washington University

Pamela Mitchell, PhD, CNRN, FAAN, Elizabeth S. Soule Professor and Associate Dean for Research, School of Nursing, University of Washington

Dori Taylor Sullivan, PhD, RN, CNA, CPHQ, Associate Professor and Chair, Department of Nursing, Sacred Heart University, Fairfield, CT

Judith Warren, PhD, RN, BC, FAAN, FACMI, Associate Professor, University of Kansas School of Nursing and Director of Nursing Informatics, KU Center for Healthcare Informatics

Contact:           Linda Cronenwett, PhD, RN, FAAN

Dean and Professor

School of Nursing

University of North Carolina at Chapel Hill

Carrington Hall, CB #7460

Chapel Hill, NC 27599-7460

(919) 966-3731

lcronenwett@unc.edu

Quality and Safety Education for Nurses is funded by the Robert Wood Johnson Foundation.

Principal Investigator, Linda R. Cronenwett, University of North Carolina at Chapel Hill

Abstract

Quality and Safety Education for Nurses (QSEN) addresses the challenge of preparing nurses with the competencies necessary to continuously improve the quality and safety of the health care systems in which they work. QSEN faculty members adapted the Institute of Medicine¹ competencies for nursing (patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics), proposing definitions that could describe essential features of what it means to be a competent and respected nurse. Using the competency definitions, the authors propose statements of the knowledge, skills, and attitudes (KSAs) for each competency that should be developed during prelicensure nursing education. QSEN faculty and advisory board members invite the profession to comment on the competencies and their definitions and on whether the KSAs for prelicensure education are appropriate goals for students preparing for basic practice as a registered nurse. 

            A series of national commissions have documented significant problems related to safety and quality in the U.S. health care system^1-5.  In light of these problems, reports from multiple national committees concluded that if health care is to improve, providers need to be prepared with a different set of competencies than are developed in educational programs today^{1, 6}.  Health professionals, using scientific evidence, need to be able to describe what constitutes good care, identify gaps between good care and the local care provided in their practices, and know what activities they could initiate, if necessary, to close any gaps⁷.  Faculties of medicine, nursing, and other health professions are challenged by the 2003 Institute of Medicine (IOM) Health Professions Education report¹ to mindfully alter learning experiences that form the basis for professional identity formation so that graduates are educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.¹

Will, ideas, and execution are required to incorporate the development of the above competencies in nursing education.  Unlike medicine, where commitment to an adapted version of the IOM competencies is now in place for the continuum from medical school to residency program to certification^8-9, nursing has no consensus on the competencies that could apply to all nurses -- that would define what it means to be a respected and qualified nurse.  At the core of nursing, however, lies incredible historical will to ensure quality and safety for patients. Evidence of valuing quality and safety competencies in nursing is evident in nursing publications^10-12, standards of practice¹³, and accreditation guidelines^14-15. The American Association of Colleges of Nursing Task Force on the Essential Patient Safety Competencies for Professional Nursing Care recently completed an enhancement to the Essentials of Baccalaureate Education for Professional Nursing Practice to include exemplars of quality and safety competencies¹⁶.  But the ideas for what to teach, how to teach, and how to assess learning of the competencies are sorely lacking, and there are few, if any, examples of schools claiming to execute a comprehensive quality and safety curriculum.

DEFINING THE COMPETENCIES

Quality and Safety Education for Nurses (QSEN), funded by the Robert Wood Johnson Foundation, was designed to address these gaps – to build on the will, to develop the ideas, and to facilitate execution of changes in nursing education.  Before teaching strategies could be developed, however, the QSEN faculty needed to identify specifically what was to be achieved.   Working with an Advisory Board of thought leaders in nursing and medicine (see acknowledgments), the authors reviewed the relevant literatures and adapted the IOM¹ competencies for nursing. The goal was to describe competencies that would apply to all registered nurses.

In Tables 1-6 below, the definitions are shared with the profession with the hope that nursing, through its professional organizations, can benefit from the work.  If nursing constituencies find these competency definitions clear and compelling, over time the competencies can serve as guides to curricular development for formal academic programs, transition to practice and continuing education programs. In addition, the definitions can provide a framework for regulatory bodies that set standards for licensure, certification, and accreditation of nursing education programs. 

PRELICENSURE NURSING EDUCATION

The competency definitions provided a broad framework for QSEN’s work to define pedagogical strategies for quality and safety education; however, as is evident in the accompanying article in this issue, when the competency names and definitions were used alone, the vast majority of prelicensure program leaders stated that they already included content related to the competencies in their curricula¹⁷.  Relying on the respondent to interpret the general definitions of the QSEN competencies, levels of satisfaction with the extent to which students developed these competencies were high, and program leaders believed that faculty possessed the necessary expertise to teach these competencies. 

QSEN faculty and advisory board members did not share the view that prelicensure nursing students were graduating with these competencies.  We knew that many students graduated without ever communicating a recommendation for a change in patient care to a physician.  Many of us knew that students learned the “five rights” of medication administration but lacked the language of common concepts related to safety sciences or quality improvement methods.  With the goal of clarifying, rather than prescribing, current meanings of the competency definitions, we outlined the knowledge, skills, and attitudes (KSAs) appropriate for prelicensure education.

During two workshops and multiple email communications, the authors led the process of KSA development.  We focused on all of prelicensure education (associate, diploma, baccalaureate and master’s entry), because the ultimate goal is to assure that all patients will be cared for by nurses who have developed the KSAs for each competency.  We tried to answer the question, “What should nursing promise with regards to its prelicensure graduates’ quality and safety education?”

At each step, we sought feedback from nursing faculty.  In contrast to the results of the survey, when nursing school faculty from 16 universities in the Institute for Healthcare Improvement Health Professions Education Collaborative reviewed the KSA draft, they uniformly reported that nursing students were not developing these KSAs.  Additional focus groups were held with faculty who taught prelicensure students in QSEN faculty members’ schools, and the responses were the same.  Although the faculty agreed that they should be teaching these competencies and, in fact, had thought they were, focus group participants did not understand fundamental concepts related to the competencies and could not identify pedagogical strategies in use for teaching the KSAs. 

A chief nurse executive serving on the QSEN advisory board led a focus group of new graduates.  Not only did these nurses report that they lacked learning experiences related to the KSAs, they did not believe their faculties had the expertise to teach some of the content.

In September, 2006, three QSEN faculty leaders presented the competencies and KSAs in a special session of the National League for Nursing (NLN) Educational Summit.  Over 100 ADN, diploma, and BSN faculty members listened to the results of the survey and contrasted those results with the responses from faculty focus groups.  Once again, this audience confirmed the focus group feedback.  Nurses and nursing faculty hold commitments to patient-centered care and safety central to their professional identities.  They consider their teaching approaches to be aimed at the development of these competencies.  Yet when educators understand the competency definitions by seeing the KSAs, they acknowledge that the KSAs represent a new view of what is required.

One additional source of feedback was obtained through written requests to leaders of advanced practice organizations that represent nurse practitioner and clinical nurse specialist faculties and accrediting bodies for nurse anesthesia and nurse-midwifery programs.  We asked whether the competency definitions were appropriate for all nurses, including advanced practice nurses, and were told they were.  We received helpful comments on the KSAs, and respondents supported the assessment that they were appropriate for prelicensure graduates. 

More presentations to faculty at national meetings are scheduled, and we expect the profession’s vision for prelicensure KSAs to evolve over time.  The current versions of the KSAs are included in Tables 1-6.  Although it is beyond the scope of this paper to describe and reference every idea presented, we include in the section below a few comments and references for each competency.

DISCUSSION OF KSAs

Patient-centered care.  The essential features of this competency were derived from work by Bezold¹⁸, the Picker Institute¹⁹, and Lorig²⁰.  Educators have worked hard on the issues related to diversity during the last years, and curricula generally address principles of communication, physical comfort, emotional support, and education.  QSEN faculty and advisory board members believed greater attention might be needed to KSAs that are concerned with eliciting and incorporating patient preferences and values in the plan of care, valuing the patient (or surrogates) as partners in care, appreciating the legal and ethical dilemmas posed by shared decision-making and developing expertise in managing conflict.  New graduates who develop the KSAs would be advocates for removing barriers to the presence of patient surrogates and would invite patients or surrogates to partner with them, for example, in safe medication administration and safe transitions in care.

Teamwork and collaboration.  The essential features of this competency include sections related to self, team, team communication and conflict resolution, effect of team on safety and quality, and the impact of systems on team functioning.^21-25   Although educators devote curricular time to fostering teamwork competence with members of the nursing team, faculty focus group participants acknowledged that little is done to foster shared mental models and communication styles essential to inter-professional team functioning.  A mandate to strengthen teamwork and collaboration skills is derived from knowledge of the relationships between quality of team communications and clinical outcomes^{23, 24}.  New graduates who develop the KSAs would use team communication practices²⁵ and seek system support for effective team functioning wherever they worked.

Evidence-based practice (EBP).  This competency provoked lengthy discussions about KSAs that would be relevant to all of prelicensure nursing education.  Many impressive guides to EBP in nursing^26-28 include approaches that require competencies not universally developed in undergraduate students.  The QSEN faculty and advisory board desired a set of KSAs that would be achievable in all prelicensure programs, recognizing that some baccalaureate and graduate-entry programs might choose to devote additional curricular time to develop additional KSAs for this competency.  Currently, all programs were perceived to be lacking in sufficient development of KSAs that go beyond ‘understanding of basic scientific methods and processes’²⁹.  New graduates who develop the KSAs would differentiate between clinical opinion and various levels of scientific evidence³⁰ and value the need for continuous improvement based on new knowledge.  They would also understand that EBP is about more than evidence – that it involves patient preferences and values and the clinical expertise necessary to understand when it is appropriate for clinicians to deviate from evidence-based guidelines in order to deliver high quality, patient-centered care. 

Quality improvement.  Although nurses value highly their contributions to quality care, the KSAs associated with this competency present unique challenges to most nursing faculty.  Course coordinators who design curricula, by and large, have not been exposed to improvement methods and tools for understanding variations in care¹⁰.  Although faculty are aware of and concerned about the IOM Quality Chasm^1-5 reports and their implications for nurses, most are unprepared to teach quality improvement concepts or demonstrate them in practice.  Faculty development and new partnerships with preceptors, nurse managers, physicians and other health professional colleagues in clinical settings will be required if students are to acquire the skills described in Table 4³¹.  New graduates who develop the KSAs would learn and use improvement methods as part of their coursework and clinical practica, and they would enter the workforce prepared to participate in improvement work as a part of their daily work as health professionals.

Safety.  Faculties take seriously their role in preparing nurses to deliver safe care to patients.  One could argue that the entire curricula and supervised hours of clinical practice are designed with future safety for patients in mind.  The bulk of the focus, however, is on teaching students the knowledge they need to care for individual patients, with limited, if any, emphasis on the immense system problems in safety.^{4-5, 32} QSEN faculty and advisory board members felt it was crucial, therefore, to have a separate ‘safety’ competency for nursing, with KSAs related to system effectiveness and reliability, in addition to the traditional foci on individual performance.  Educational needs assessments have been published, ³³ and faculty are beginning to address safety issues in new ways, such as medication errors involving students^34-35.   New graduates who develop the KSAs will know about human factors and safety design principles, understand the importance of error reporting and safety cultures, and value vigilance and cross-monitoring among patients, families, and members of the health care team.

Informatics.  In the QSEN survey, ¹⁷ as well as another recent survey where the topic was solely about informatics, ³⁶ it is clear that nursing faculty are uncertain about what and how to teach about informatics.  Yet health professionals and patients will rely increasingly on information technology to communicate, manage knowledge, mitigate error, and support decision making.^37-38   The QSEN faculty and advisory board members argued that basic informatics KSAs were essential for developing the other five QSEN competencies.  New graduates who develop the KSAs in informatics will be able to participate in the design, selection, and evaluation of information technologies used in the support of patient care.  They will learn to navigate an electronic health record and experiment with communication technologies to support coordination and safe, effective transitions in care.

SUMMARY

At the core of nursing lies incredible historical will to ensure quality and safety for patients.  Many current endeavors, such as the work occurring in the Robert Wood Johnson Foundation-sponsored project, Transforming Care at the Bedside, demonstrate how quality/safety/improvement work attracts the hearts of nurses, resulting in the “joy in work”⁷ that retains the health care workforce.  Attending to the development of QSEN competencies may help nurses -- who love the basic work of nursing -- love their jobs, too. 

To assure new graduate competencies in patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics, all of nursing education must embrace the need for change.  These competencies cannot be mastered through a didactic approach nor developed in a single course or web-based module.  Every clinical instructor will have to engage differently with the inter-professional team on patient care units where they are teaching.  Simulation cases will include components that address the QSEN competencies.  Reflective papers and case studies will be used to deepen understanding of the values and attitudes required for quality and safety work.  By the time this article is published, the www.qsen.org website will be populated with dozens of beginning ideas for teaching the development of the QSEN competencies in classrooms, clinical settings, and skills/simulation labs.  We invite the profession to use, critique, and continuously improve the KSAs, submit strategies to the QSEN website, and share what is learned as we attempt, each in our own way, to create a future where nurses are prepared with the competencies called for in the IOM Health Professions Education¹ report.  As the most trusted profession, we owe ourselves and our patients nothing less.  

Acknowledgments

The authors gratefully acknowledge the following QSEN faculty and Advisory Board members for their contributions to the development of the competency definitions and KSAs:  Paul Batalden, MD, (Dartmouth); Geraldine Bednash, PhD, RN, FAAN, (American Association of Colleges of Nursing); Jean Blackwell, MLS (UNC-Chapel Hill); Lisa Day, PhD, RN (UC-San Francisco); Karen Drenkard, PhD, RN, CNAA, (Inova Health System); Carol Durham, EdD(c), MSN, RN, (UNC-Chapel Hill); Leslie Hall, MD (U Missouri-Columbia); Pamela Ironside, PhD, RN, FAAN, (Indiana University); Mary (Polly) Johnson, MSN, RN, FAAN (NC Board of Nursing); Maryjoan Ladden, PhD, RN, (Harvard); Shirley Moore, PhD, RN, FAAN, (Case Western Reserve University); Audrey Nelson, PhD, RN, FAAN (Veterans Administration-Tampa); Elaine  Smith EdD(c), MBA, MSN, RN, CNAA (UNC-Chapel Hill); M. Elaine Tagliareni, EdD, RN (Community College of Philadelphia).

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